The 21st Annual Fees and Reimbursements Survey

Hannah FellOctober 9, 2018

A breakdown of chiropractic fees and reimbursements across the industry for 2018

See where your practice stands in relation to national results.

Last year, we saw an overall leveling of fees and reimbursements from our post-recession economy. This trend has continued this year among our survey participants and we have seen additional growth. Chiropractic has been seen as a viable option to fight the opioid epidemic, and we have seen ample research to back up its effectiveness.

In particular, this year, chiropractic has been elevated as a viable solution for pain management by the medical community. In 2017, the American College of Physicians updated its treatment guidelines to recommend that non-invasive approaches to pain management should be used before resorting to drugs.1 As a result, more people are turning to chiropractic care, and research into the effectiveness of chiropractic will only continue to legitimize the field.2

The results from our survey remained consistent with several trends we have been seeing over the past few years. Fees climbed smartly from $68 in 2017 to $77 in 2018. Reimbursement numbers came in at about $45 this year, a slight increase from $44 in 2017. These trends continue to reflect modest but steady financial growth in the chiropractic industry.

According to the data collected from chiropractic school enrollments, it’s apparent that more women have started entering the industry. Over the past few years, we have started to see those numbers trend positively in our survey, as more women have responded to our calls to take the survey. This year, we had the highest number of women respondents that we have seen yet at 27 percent of total replies. Hopefully, as time passes, we will continue to see more women enter the chiropractic field.

Although the economy as a whole is looking strong in terms of growth and employment, with inflation in check, the health care industry (MDs, DCs and specialists) has been in a holding pattern. It is possible that uncertainty in the insurance markets, along with rising co-pays and deductibles, have consumers skittish about health care services in general, presenting a countervailing headwind against positive economic trends.

It is likely, then, that if and when some measure of certainty and stability return to the health care environment, an upturn in business can be expected.

As always, our survey is subject to statistical variation, and all figures herein presented should be considered as approximate. Normal fluctuations in most categories occur year over year, and we suggest that our results are best used for spotting general trends, and guiding your strategic planning.

Below, you will find several key points from this year’s Fees and Reimbursements survey:

The Midwest wins. Like last year, the Midwest reported the highest percentage of reimbursement rates in 2018 at 81 percent. This finding surpassed last year’s findings where the Midwest had the highest reimbursement rate at 66.6 percent.

Group work. This year, 24 percent of respondents reported operating in a group setting. This remained relatively the same from last year in 2017, where 27 percent reported working in a group, which was the highest percentage of group practice participants recorded in 19 years. The most common specialist in the group was a massage therapist, which was indicated by 53 percent of groups with specialists on board. This finding suggests that the percentage of chiropractors in groups working with specialists is on the rise.

Additionally, group practices had average fees of $75 and average reimbursements of $40, while solo practices had average fees and reimbursements of $73 and $38.

Cash only. Cash-based practices are on the rise. They had been on the decline for the past few years, according to Chiropractic Economics survey results. In 2016, 13 percent of practices were cash only, and in 2017, we saw that number decrease even more to about 10 percent. However, this year, we saw that number rise to 12 percent.

Payment plans. Although payment plans have been declining over the past few years, this year the overall percentage decreased just slightly by about 3 percent. However, the biggest improvement in payment options this year is in DCs offering a discount for cash. Our survey results showed that about 33 percent of DCs currently offer this type of plan.

Keeping it regional

Nationwide, the average fees and reimbursements collected among chiropractic practices continue to vary by region, and generally change year over year. Similar to our findings from last year, the West reported the highest average fees in 2018 at $87. Surprisingly, this year the East followed close behind at $79.

While overall fees ($77) jumped this year, reimbursements also mirrored last year’s $43.5. The reimbursement rate is 64 percent, which is a slight decrease from last year’s average reimbursement rate of 65 percent.

The West reported the highest average reimbursements at $64 (up from $48 last year).

The East had the second highest average fees but trailed the West with an average reimbursement rate of 66 percent, up from last year’s rate of 60 percent.

The Midwest had a reimbursement rate of 81 percent—an increase from the previous year’s at 67 percent.

So far, so good

Last year we described an era of increased confidence in the chiropractic industry, with an overall leveling of fees and reimbursements post-recession. That consistency remained true among our 2018 survey participants, with some additional signs of growth.

Our annual survey showed that fees remained about the same from $68 in 2017 to $68 in 2018. Reimbursement followed a similar trend, with the numbers remaining at $44 from 2017 to $44 once again in 2018. The overall reimbursement rates decreased slightly, from 64.7 percent last year to 63.8 percent this year.

The last three years’ reimbursement rates have held steady between around 61 and 65 percent, and this year we saw the numbers remain among those averages. While only time will tell how major changes in health care will affect the industry, this year’s results show a consistency that indicates a stable chiropractic market for the time being.

Team play

This year, 24 percent of our survey participants reported operating in a group setting. This finding remained relatively the same from last year in 2017, where 28 percent reported working in a group.

A total of 7 percent of responses were from associates, and about 6 percent indicate they’re working as independent contractors in a practice. At 63 percent, DCs with solo practices made up the majority of respondents.

Group practices reported higher fees, reimbursements, and reimbursement rates than solo operations. Group practices had average fees of $75 and average reimbursements of $40, while solo practices had average fees and reimbursements of $73 and $38, respectively.

Reimbursement rates in group practices decreased from last year’s 67 percent to 52 percent this year, and solo practices decreased from 67 percent to 61 percent over the same period.

As expected, group practices reported a higher percentage of specialists working in their clinics. About 50 percent of solo DCs answered “none” when asked what specialists they employed, while just 23 percent of group practitioners answered the same. The most common specialist in a group practice is an LMT, which 53 percent of group specialists reported.

DCs and MDs

The ebb and flow of reimbursements in the chiropractic field often mirror what’s happening in the health care industry as a whole, albeit to a different or lesser extent. These parallels can be seen when evaluating the common codes shared by DCs and MDs alike, and specifically code 99201 (evaluation and management for new patients) and its variations 99202, 99203, and 99204.

For example, last year, the overall decline in MD reimbursements recorded by Physicians Practice, a business journal for medical doctors, was in contrast with the slight growth or leveling of these same codes for DCs. While the dollar value of MD reimbursements for these codes remained higher on average than those values reported by their DC counterparts (even with the declining reimbursements), our results show a widening financial gap between the professions with regard to these core codes.

In 2018, DCs (per this survey) and MDs (according to insurance company estimates) reported mixed reimbursements on average for all four codes. DC fees for all four codes fell, and except for code 99201, MDs were seen to be reimbursed at a higher rate.

The increase in reimbursements reported by MDs was in some cases steeper than declines indicated by chiropractors. So, while both industries bill for these codes, the 2017–18 results illustrate a return to a broader cleft dividing the industries, with MDs experiencing a recession recovery at a faster rate.

Because the MD data we obtained applies to solely to reimbursements, our comparisons will be limited to DC reimbursements as well. The breakdown of specific codes in 2017–18 is as follows:

For code 99201, DCs averaged reimbursements of $35.60, while MDs’ reimbursements were $52.77. This is down from $49 (DCs) and a decrease from $66 (MDs) from last year’s results.

For code 99202, MDs’ reimbursements were $91, up from $82 the previous year, and DCs reported an average of $50, down from $63 in 2017.

For code 99203, MDs’ reimbursements increased from $101 last year to $130 this year. DCs’ reimbursements also decreased slightly from $86 last year to $71 this year.

For code 99204, MDs reported a reimbursement average of $201, a substantial increase from last year’s $131. Chiropractors reported average reimbursement of $86, which is a sharp decrease from last year’s $110.

"reimbursements as well. The breakdown of specific codes in 2017 is as follows:""For code 99201, DCs averaged reimbursements of $49, while MDs’ reimbursements were $66. This is down from""$50 (DCs) and remained the same $66 (MDs) from last year.""For code 99202, MDs’ reimbursements were $82, up from $81 the previous year, and DCs reported an average of $63, down slightly from $64 in 2016.""For code 99203, MDs’ reimbursements decreased slightly from $101 last year to $98 this year. DCs’ reim- bursements were unchanged from $86 last year to $84 this year.""For code 99204, MDs reported a reimbursement average of $131, a slight increase from last year’s $130. Chiropractors reported average reimbursements of $110, which was a slight jump from last year. l"

Specialties, anyone?

In May 2018, our Salary and Expense Survey showed multidisciplinary and integrated practices achieving new levels of success, and increased salaries and reimbursement rates have followed. Chiropractors who have been in the industry longer have seen larger paychecks. Those salary survey participants with specialists working within their practice reported average earnings of more than $144,750, compared to the $107,300 reported by strictly solo operations.

In addition, multidisciplinary practices reported higher fees and reimbursements than those without specialists. The results demonstrate the multifaceted benefits of running a practice with diverse specialties.

Specifically, practices with specialists reported average fees and reimbursements of $78 and $43, while non-specialist practices reported average fees and reimbursements of $69 and $31, respectively.

Specifically, practices with specialists reported average fees and reimbursements of $68 and $45, while non-specialist practices reported average fees and reimbursements of $61 and $42, respectively.

For multidisciplinary practices, licensed massage therapists (LMT) remained the most popular practice add-on, with 40 percent having one on board. LMT was followed by physical therapist (15 percent), acupuncturist (14 percent), fitness trainer (6 percent), nutritionist (5 percent), and MD/DO (5 percent). The 3 percent who answered “other” specified working with such specialists as exercise physiologists, psychologists, chiropractic interns, and a Pilates instructor.

Portrait of a franchise

Although we saw an increase in survey participants reporting as franchises over the past three years, we saw the percentage drop slightly in 2017 to 4 percent. This year, that number rose back to 5 percent.

The financial picture for franchisees increased slightly from last year’s survey. The average reimbursement increased from 66 percent last year to 67 percent this year. Also, fees increased from $65 to $76 this year. Reimbursements were at $53 this year compared to $49 last year.

By the book: This year’s survey indicates that franchise owners are the same average age as the overall group of chiropractors (50 years old). In addition, 80 percent of respondents reporting as franchisees in 2018 were male, a figure which held true from last year’s survey and is unchanged.

The average franchise owner has been practicing for 20 years (compared to the 21 year average among all respondents), owns one practice, and is licensed in one state.

This year’s survey showed that the vast majority of franchise owners are still operating a solo practice (69 percent). But those running a group practice increased from 40 percent in 2017 to 41 percent in 2018. This year, 11 percent of respondents in a franchise were independent contractors in a practice.

Cash only

Although the percentage of cash-only practice survey participants decreased from 13 percent in 2016 to 10 percent in 2017, we saw a rise to approximately 12 percent in cash-only practices this year. Those DCs who did report operating a cash-based practice fared well in their collections.

For cash-based practices, average fees were reported at $77, an amount that is equal to the overall average fees. In 2016, cash fees came in at $74, then increased slightly to $77 in 2017, so this year’s data serves as an indication that cash collections continue to be on the rise.

By strict definition, a cash-based practice would have no reimbursements. So fees in a cash-only practice are equivalent to reimbursements (collections). Cash-only practices fees of $77 are 57 percent above the overall average reimbursement rate of $44.

This year we asked what percentage of your collections is cash-based to dig deeper into this type of practice. Almost 36 percent answered that their practice had less than 25 percent cash income. Twenty-nine percent reported being at 25–50 percent cash, and 22 percent had 50–75 percent cash collections.

Your typical cash-only practice respondent is male (80 percent). Cash-based practice survey participants had an average age of 50, and typically work in a solo clinic (78 percent). These respondents have been working as a practitioner for 21 years on average.

Regarding cash-only practice offerings:

Instrument adjusting (68 percent)

​Ultrasound (61 percent)

​Electrotherapy (60 percent)

​Nutrition (57 percent)

Kinesio taping (54 percent)

​Exercise programs (53 percent)

Massage therapy (51 percent)

Physical therapy (44 percent)

Laser therapy (40 percent)

IASTM (29 percent)

Acupuncture (23 percent)

​Homeopathy (13 percent)

He said, she said

Over the past few years, the number of female survey respondents has hovered around one-quarter of all participants. In 2012, we saw an all-time high of 28 percent, and last year, 22 percent of our respondents were female. In 2018, we are pleased to see that number rise once again, reaching 27 percent female respondents.

The 56 percent reimbursement rate for men is down from 66 percent last year, and reimbursement rates for women are down from 55 percent last year.

Women respondents reported an average younger age (49), compared to men (51). In addition, female DCs reported being in practice for fewer years (20), while male respondents have been in practice for an average of 23 years.

With regard to modalities, instrument adjusting (75 percent), kinesiotaping (59 percent) and exercise programs (54 percent) were the most popular among women. The most popular modality reported by male practitioners was instrument adjusting (65 percent). Electrotherapy was another popular modality among males (63 percent) as well as ultrasound (59 percent).

Payment options

The number of doctors offering payment plans to patients this year decreased slightly overall (49 percent compared to 53 percent in 2017). The 2018 results show just a minor decrease, and could be due to routine fluctuations in the types of payment plans chiropractors have been offering.

The biggest improvement this year is in DCs offering a discount for cash. Last year, 32 percent of DCs offered a discount for cash, and this year about 33 percent of DCs have this type of plan in place.

And while negotiations per case saw a decline from nearly 38 percent last year to 26 percent this year, that number had been growing slightly over time from about 27 in 2016. Although these are wide variations, the numbers should fall into place within the next few years and reach an equilibrium.

Stick to the code

Every year, we ask doctors of chiropractic to report on three additional codes: 95851, range-of-motion testing; 95831, muscle testing; and 97750, physical-performance evaluation. It should be noted that we did include these codes when calculating the fees and reimbursement averages for the other sections, not including the regional comparison chart.

Average fees for range-of-motion testing were $55, while average reimbursements were $33.5—a reimbursement rate of 61 percent.

Average fees for muscle testing were $51, with an average reimbursement of $30—a reimbursement rate of 59 percent.

Average fees for physical-performance evaluation were $86, with an average reimbursement of $55, and a reimbursement rate of 64 percent.

Hannah Fell is the associate editor of Chiropractic Economics and MASSAGE Magazine. She can be reached at hfell@chiroeco.com.